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D S M - I V- T R C L A S S I F I C AT I O N * NOS = Not Otherwise Specified An x appearing in a diagnostic code indicates that a specific code number is required. An ellipsis (. . .) is used in the names of certain disorders to indicate that the name of a specific mental disorder or general medical condition should be inserted when recording the name (e.g., 293.0 Delirium Due to Hypothyroidism). Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence MENTAL RETARDATION Note: These are coded on Axis II. 317 Mild Mental Retardation 318.0 Moderate Mental Retardation 318.1 Severe Mental Retardation 318.2 Profound Mental Retardation 319 Mental Retardation, Severity Unspecified LEARNING DISORDERS 315.00 315.1 315.2 315.9 Reading Disorder Mathematics Disorder Disorder of Written Expression Learning Disorder NOS MOTOR SKILLS DISORDER 315.4 Developmental Coordination Disorder If criteria are currently met, one of the following severity specifiers may be noted after the diagnosis: Mild Moderate Severe If criteria are no longer met, one of the following specifiers may be noted: In Partial Remission In Full Remission Prior History 312.xx Conduct Disorder .81 Childhood-Onset Type .82 Adolescent-Onset Type .89 Unspecified Onset 313.81 Oppositional Defiant Disorder 312.9 Disruptive Behavior Disorder NOS FEEDING AND EATING DISORDERS OF INFANCY OR EARLY CHILDHOOD 307.52 Pica 307.53 Rumination Disorder 307.59 Feeding Disorder of Infancy or Early Childhood TIC DISORDERS 307.23 Tourette’s Disorder 307.22 Chronic Motor or Vocal Tic Disorder 307.21 Transient Tic Disorder Specify if: Single Episode/Recurrent COMMUNICATION DISORDERS 307.20 Tic Disorder NOS 315.31 315.32 315.39 307.0 307.9 ELIMINATION DISORDERS Expressive Language Disorder Mixed Receptive-Expressive Language Disorder Phonological Disorder Stuttering Communication Disorder NOS ____.__ 787.6 307.7 307.6 PERVASIVE DEVELOPMENTAL DISORDERS 299.00 299.80 299.10 299.80 299.80 Autistic Disorder Rett’s Disorder Childhood Disintegrative Disorder Asperger’s Disorder Pervasive Developmental Disorder NOS ATTENTION-DEFICIT AND DISRUPTIVE BEHAVIOR DISORDERS 314.xx Attention-Deficit/Hyperactivity Disorder .01 Combined Type .00 Predominantly Inattentive Type .01 Predominantly Hyperactive-Impulsive Type 314.9 Attention-Deficit/Hyperactivity Disorder NOS Encopresis With Constipation and Overflow Incontinence Without Constipation and Overflow Incontinence Enuresis (Not Due to a General Medical Condition) Specify type: Nocturnal Only/Diurnal Only/Nocturnal and Diurnal OTHER DISORDERS OF INFANCY, CHILDHOOD, OR ADOLESCENCE 309.21 Separation Anxiety Disorder Specify if: Early Onset 313.23 Selective Mutism 313.89 Reactive Attachment Disorder of Infancy or Early Childhood Specify type: Inhibited Type/Disinhibited Type 307.3 Stereotypic Movement Disorder Specify if: With Self-Injurious Behavior *Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Copyright 2000 American Psychiatric Association. ■ Appendix DSM-IV-TR Classification 313.9 Disorder of Infancy, Childhood, or Adolescence NOS Delirium, Dementia, and Amnestic and Other Cognitive Disorders DELIRIUM 293.0 Delirium Due to . . . [Indicate the General Medical Condition] ____.__ Substance Intoxication Delirium (refer to Substance-Related Disorders for substancespecific codes) ____.__ Substance Withdrawal Delirium (refer to Substance-Related Disorders for substancespecific codes) ____.__ Delirium Due to Multiple Etiologies (code each of the specific etiologies) 780.09 Delirium NOS DEMENTIA 294.xx* Dementia of the Alzheimer’s Type, With Early Onset (also code 331.0 Alzheimer’s disease on Axis III) .10 Without Behavioral Disturbance .11 With Behavioral Disturbance 294.xx* Dementia of the Alzheimer’s Type, With Late Onset (also code 331.0 Alzheimer’s disease on Axis III) .10 Without Behavioral Disturbance .11 With Behavioral Disturbance 290.xx Vascular Dementia .40 Uncomplicated .41 With Delirium .42 With Delusions .43 With Depressed Mood Specify if: With Behavioral Disturbance Code presence or absence of a behavioral disturbance in the fifth digit for Dementia Due to a General Medical Condition: 0 = Without Behavioral Disturbance 1 = With Behavioral Disturbance 294.1x* Dementia Due to HIV Disease (also code 042 HIV on Axis III) 294.1x* Dementia Due to Head Trauma (also code 042 HIV on Axis III) 294.1x* Dementia Due to Head Trauma (also code 854.00 head injury on Axis III) 294.1x* Dementia Due to Parkinson’s Disease (also code 332.0 Parkinson’s disease on Axis III) 294.1x* Dementia Due to Huntington’s Disease (also code 333.4 Huntington’s disease on Axis III) 294.1x* Dementia Due to Pick’s Disease (also code 331.1 Pick’s disease on Axis III) 294.1x* Dementia Due to Creutzfeldt-Jakob Disease (also code 046.1 Creutzfeldt-Jakob disease on Axis III) 294.1x* Dementia Due to . . . [Indicate the General Medical Condition not listed above] (also code the general medical condition on Axis III) ____.__ Substance-Induced Persisting Dementia (refer to Substance-Related Disorders for substancespecific codes) ____.__ Dementia Due to Multiple Etiologies (code each of the specific etiologies) 294.8 Dementia NOS AMNESTIC DISORDERS 294.0 Amnestic Disorder Due to . . . [Indicate the General Medical Condition] Specify if: Transient/Chronic ____.__ 294.8 Substance-Induced Persisting Amnestic Disorder (refer to Substance-Related Disorders for substance-specific codes) Amnestic Disorder NOS OTHER COGNITIVE DISORDERS 294.9 Cognitive Disorder NOS Mental Disorders Due to a General Medical Condition Not Elsewhere Classified 293.89 Catatonic Disorder Due to . . . [Indicate the General Medical Condition] 310.1 Personality Change Due to . . . [Indicate the General Medical Condition] Specify type: Labile Type/Disinhibited Type/Aggressive Type/Apathetic Type/Paranoid Type/Other Type/Combined Type/Unspecified Type 293.9 Mental Disorder NOS Due to . . . [Indicate the General Medical Condition] Substance-Related Disorders The following specifiers apply to Substance Dependence as noted: aWith Physiological Dependence/Without Physiological Dependence bEarly Full Remission/Early Partial Remission/Sustained Full Remission/Sustained Partial Remission cIn a Controlled Environment dOn Agonist Therapy The following specifiers apply to Substance-Induced Disorders as noted: IWith Onset During Intoxication/WWith Onset During Withdrawal ALCOHOL-RELATED DISORDERS Alcohol Use Disorders 303.90 Alcohol Dependencea,b,c 305.00 Alcohol Abuse Alcohol-Induced Disorders 303.00 Alcohol Intoxication 291.81 Alcohol Withdrawal Specify if: With Perceptual Disturbances * ICD-9-CM code valid after October 1, 2000. 291.0 Alcohol Intoxication Delirium Appendix DSM-IV-TR Classification ■ 291.0 291.2 291.1 291.x .5 .3 291.89 291.89 291.89 291.89 291.9 Alcohol Withdrawal Delirium Alcohol-Induced Persisting Dementia Alcohol-Induced Persisting Amnestic Disorder Alcohol-Induced Psychotic Disorder With DelusionsI,W With HallucinationsI,W Alcohol-Induced Mood DisorderI,W Alcohol-Induced Anxiety DisorderI,W Alcohol-Induced Sexual DysfunctionI Alcohol-Induced Sleep DisorderI,W Alcohol-Related Disorder NOS AMPHETAMINE (OR AMPHETAMINE-LIKE)–RELATED DISORDERS Amphetamine Use Disorders 304.40 Amphetamine Dependencea,b,c 305.70 Amphetamine Abuse Cocaine-Induced Disorders 292.89 Cocaine Intoxication Specify if: With Perceptual Disturbances 292.0 292.81 292.xx .11 .12 292.84 292.89 292.89 292.89 292.9 Cocaine Withdrawal Cocaine Intoxication Delirium Cocaine-Induced Psychotic Disorder With DelusionsI With HallucinationsI Cocaine-Induced Mood DisorderI,W Cocaine-Induced Anxiety DisorderI,W Cocaine-Induced Sexual DysfunctionI Cocaine-Induced Sleep DisorderI,W Cocaine-Related Disorder NOS HALLUCINOGEN-RELATED DISORDERS Hallucinogen Use Disorders 304.50 Hallucinogen Dependenceb,c 305.30 Hallucinogen Abuse Amphetamine-Induced Disorders Hallucinogen-Induced Disorders 292.89 Amphetamine Intoxication 292.89 Hallucinogen Intoxication 292.89 Hallucinogen Persisting Perception Disorder (Flashbacks) 292.81 Hallucinogen Intoxication Delirium 292.xx Hallucinogen-Induced Psychotic Disorder .11 With DelusionsI .12 With HallucinationsI 292.84 Hallucinogen-Induced Mood DisorderI 292.89 Hallucinogen-Induced Anxiety DisorderI 292.9 Hallucinogen-Related Disorder NOS Specify if: With Perceptual Disturbances 292.0 292.81 292.xx .11 .12 292.84 292.89 292.89 292.89 292.9 Amphetamine Withdrawal Amphetamine Intoxication Delirium Amphetamine-Induced Psychotic Disorder With DelusionsI With HallucinationsI Amphetamine-Induced Mood DisorderI,W Amphetamine-Induced Anxiety DisorderI Amphetamine-Induced Sexual DysfunctionI Amphetamine-Induced Sleep DisorderI,W Amphetamine-Related Disorder NOS CAFFEINE-RELATED DISORDERS Caffeine-Induced Disorders 305.90 292.89 292.89 292.9 Caffeine Intoxication Caffeine-Induced Anxiety DisorderI Caffeine-Induced Sleep DisorderI Caffeine-Related Disorder NOS CANNABIS-RELATED DISORDERS Cannabis Use Disorders 304.30 Cannabis Dependencea,b,c 305.20 Cannabis Abuse Cannabis-Induced Disorders 292.89 Cannabis Intoxication Specify if: With Perceptual Disturbance 292.81 292.xx .11 .12 292.89 292.9 Cannabis Intoxication Delirium Cannabis-Induced Psychotic Disorder With DelusionsI With HallucinationsI Cannabis-Induced Anxiety DisorderI Cannabis-Related Disorder NOS COCAINE-RELATED DISORDERS Cocaine Use Disorders 304.20 Cocaine Dependencea,b,c 305.60 Cocaine Abuse INHALANT-RELATED DISORDERS Inhalant Use Disorders 304.60 Inhalant Dependenceb,c 305.90 Inhalant Abuse Inhalant-Induced Disorders 292.89 292.81 292.82 292.xx .11 .12 292.84 292.89 292.9 Inhalant Intoxication Inhalant Intoxication Delirium Inhalant-Induced Persisting Dementia Inhalant-Induced Psychotic Disorder With DelusionsI With HallucinationsI Inhalant-Induced Mood DisorderI Inhalant-Induced Anxiety DisorderI Inhalant-Related Disorder NOS NICOTINE-RELATED DISORDERS Nicotine Use Disorder 305.1 Nicotine Dependencea,b Nicotine-Induced Disorder 292.0 292.9 Nicotine Withdrawal Nicotine-Related Disorder NOS OPIOID-RELATED DISORDERS Opioid Use Disorders 304.00 Opioid Dependencea,b,c,d 305.50 Opioid Abuse ■ Appendix DSM-IV-TR Classification Opioid-Induced Disorders 292.89 Opioid Intoxication Specify if: With Perceptual Disturbances 292.0 292.81 292.xx .11 .12 292.84 292.89 292.89 292.9 Opioid Withdrawal Opioid Intoxication Delirium Opioid-Induced Psychotic Disorder With DelusionsI With HallucinationsI Opioid-Induced Mood DisorderI Opioid-Induced Sexual DysfunctionI Opioid-Induced Sleep DisorderI,W Opioid-Related Disorder NOS PHENCYCLIDINE (OR PHENCYCLIDINE-LIKE)–RELATED DISORDERS Phencyclidine Use Disorders 292.89 Sedative-, Hypnotic-, or Anxiolytic-Induced Anxiety DisorderW 292.89 Sedative-, Hypnotic-, or Anxiolytic-Induced Sexual DysfunctionI 292.89 Sedative-, Hypnotic, or Anxiolytic-Induced Sleep DisorderI,W 292.9 Sedative-, Hypnotic, or Anxiolytic-Related Disorder NOS POLYSUBSTANCE-RELATED DISORDER 304.80 Polysubstance Dependencea,b,c,d OTHER (OR UNKNOWN) SUBSTANCE-RELATED DISORDERS Other (or Unknown) Substance Use Disorders 304.60 Phencyclidine 305.90 Phencyclidine Abuse 304.90 Other (or Unknown) Substance Dependencea,b,c,d 305.90 Other (or Unknown) Substance Abuse Phencyclidine-Induced Disorders Other (or Unknown) Substance-Induced Disorders Dependenceb,c 292.89 Phencyclidine Intoxication Specify if: With Perceptual Disturbances 292.81 Phencyclidine Intoxication Delirium 292.xx Phencyclidine-Induced Psychotic Disorder .11 With DelusionsI .12 With HallucinationsI 292.84 Phencyclidine-Induced Mood DisorderI 292.89 Phencyclidine-Induced Anxiety DisorderI 292.9 Phencyclidine-Related Disorder NOS SEDATIVE-, HYPNOTIC-, OR ANXIOLYTIC-RELATED DISORDERS Sedative, Hypnotic, or Anxiolytic Use Disorders 304.10 Sedative, Hypnotic, or Anxiolytic Dependencea,b,c 305.40 Sedative, Hypnotic, or Anxiolytic Abuse Sedative-, Hypnotic-, or Anxiolytic-Induced Disorders 292.89 Sedative, Hypnotic, or Anxiolytic Intoxication 292.0 Sedative, Hypnotic, or Anxiolytic Withdrawal Specify if: With Perceptual Disturbances 292.81 Sedative, Hypnotic, or Anxiolytic Intoxication Delirium 292.81 Sedative, Hypnotic, or Anxiolytic Withdrawal Delirium 292.82 Sedative, Hypnotic, or Anxiolytic-Induced Persisting Dementia 292.83 Sedative-, Hypnotic-, or Anxiolytic-Induced Persisting Amnestic Disorder 292.xx Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic Disorder .11 With DelusionsI,W .12 With HallucinationsI,W 292.84 Sedative-, Hypnotic-, or Anxiolytic-Induced Mood DisorderI,W 292.89 Other (or Unknown) Substance Intoxication Specify if: With Perceptual Disturbances 292.0 Other (or Unknown) Substance Withdrawal Specify if: With Perceptual Disturbances 292.81 Other (or Unknown) Substance-Induced Delirium 292.82 Other (or Unknown) Substance-Induced Persisting Dementia 292.83 Other (or Unknown) Substance-Induced Persisting Amnestic Disorder 292.xx Other (or Unknown) Substance-Induced Psychotic Disorder .11 With DelusionsI,W .12 With HallucinationsI,W 292.84 Other (or Unknown) Substance-Induced Mood DisorderI,W 292.89 Other (or Unknown) Substance-Induced Anxiety DisorderI,W 292.89 Other (or Unknown) Substance-Induced Sexual DysfunctionI 292.89 Other (or Unknown) Substance-Induced Sleep DisorderI,W 292.9 Other (or Unknown) Substance-Related Disorder NOS POLYSUBSTANCE-RELATED DISORDER 304.80 Polysubstance Dependencea,b,c,d OTHER (OR UNKNOWN) SUBSTANCE-RELATED DISORDERS Other (or Unknown) Substance Use Disorders 304.90 Other (or Unknown) Substance Dependencea,b,c,d 305.90 Other (or Unknown) Substance Abuse Other (or Unknown) Substance-Induced Disorders 292.89 Other (or Unknown) Substance Intoxication Specify if: With Perceptual Disturbances 292.0 Other (or Unknown) Substance Withdrawal Specify if: With Perceptual Disturbances Appendix DSM-IV-TR Classification ■ 292.81 Other (or Unknown) Substance-Induced Delirium 292.82 Other (or Unknown) Substance-Induced Persisting Dementia 292.83 Other (or Unknown) Substance-Induced Persisting Amnestic Disorder 292.xx Other (or Unknown) Substance-Induced Psychotic Disorder .11 With DelusionsI,W .12 With HallucinationsI,W 292.84 Other (or Unknown) Substance-Induced Mood DisorderI,W 292.89 Other (or Unknown) Substance-Induced Anxiety DisorderI,W 292.89 Other (or Unknown) Substance-Induced Sexual DysfunctionI 292.89 Other (or Unknown) Substance-Induced Sleep DisorderI,W 292.9 Other (or Unknown) Substance-Related Disorder NOS Schizophrenia and Other Psychotic Disorders 295.xx Episodic With Interepisode Residual Symptoms (Specify if: With Prominent Negative Symptoms)/Episodic With No Interepisode Residual Symptoms Continuous (Specify if: With Prominent Negative Symptoms) Single Episode in Partial Remission (Specify if: With Prominent Negative Symptoms)/Single Episode in Full Remission Other or Unspecified Pattern .30 Paranoid Type .10 Disorganized Type .20 Catatonic Type .90 Undifferentiated Type .60 Residual Type 295.40 Schizophreniform Disorder Specify if: Without Good Prognostic Features/With Good Prognostic Features 295.70 Schizoaffective Disorder Specify type: Bipolar Type/Depressive Type Delusional Disorder Specify type: Erotomanic Type/Grandiose Type/Jealous Type/Persecutory Type/Somatic Type/Mixed Type/Unspecified Type 298.8 Brief Psychotic Disorder Specify if: With Marked Stressor(s)/Without Marked Stressor(s)/With Postpartum Onset 297.3 293.xx Shared Psychotic Disorder Psychotic Disorder Due to . . . [Indicate the General Medical Condition] .81 With Delusions .82 With Hallucinations Substance-Induced Psychotic Disorder (refer to Substance-Related Disorders for substancespecific codes) Specify if: With Onset During Intoxication/With Onset During Withdrawal 298.9 Psychotic Disorder NOS Mood Disorders Code current state of Major Depressive Disorder or Bipolar I Disorder in fifth digit: 1 = Mild 2 = Moderate 3 = Severe Without Psychotic Features 4 = Severe With Psychotic Features Specify: Mood-Congruent Psychotic Features/MoodIncongruent Psychotic Features 5 = In Partial Remission 6 = In Full Remission 0 = Unspecified The following specifiers apply (for current or most recent episode) to Mood Disorders as noted: aSeverity/Psychotic/Remission Specifiers/bChronic/cWith Catatonic Features/dWith Melancholic Features/eWIth Atypical Features/fWith Postpartum Onset Schizophrenia The following Classification of Longitudinal Course applies to all subtypes of Schizophrenia: 297.1 ____.__ The following specifiers apply to Mood Disorders as noted: gWith or Without Full Interepisode Recovery/hWith Seasonal Pattern/iWith Rapid Cycling DEPRESSIVE DISORDERS 296.xx Major Depressive Disorder .2x Single Episodea,b,c,d,e,f .3x Recurrenta,b,c,d,e,f,g,h 300.4 Dysthymic Disorder Specify if: Early Onset/Late Onset Specify if: With Atypical Features 311 Depressive Disorder NOS BIPOLAR DISORDERS 296.xx Bipolar I Disorder .0x Single Manic Episodea,c,f Specify if: Mixed .40 Most Recent Episode Hypomanicg,h,i .4x Most Recent Episode Manica,c,f,g,h,i .6x Most Recent Episode Mixeda,c,f,g,h,i .5x Most Recent Episode Depresseda,b,c,d,e,f,g,h,i .7 Most Recent Episode Unspecifiedg,h,i 296.89 Bipolar II Disordera,b,c,d,e,f,g,h,i Specify (current or most recent episode): Hypomanic/Depressed 301.13 Cyclothymic Disorder 296.80 Bipolar Disorder NOS 293.83 Mood Disorder Due to . . . [Indicate the General Medical Condition] Specify type: With Depressive Features/With Major Depressive-Like Episode/With Manic Features/With Mixed Features ■ Appendix DSM-IV-TR Classification ____.__ Substance-Induced Mood Disorder (refer to Substance-Related Disorders for substancespecific codes) Factitious Disorders 296.90 Mood Disorder NOS 300.xx Factitious Disorder .16 With Predominantly Psychological Signs and Symptoms .19 With Predominantly Physical Signs and Symptoms .19 With Combined Psychological and Physical Signs and Symptoms 300.19 Factitious Disorder NOS Anxiety Disorders Dissociative Disorders Specify type: With Depressive Features/With Manic Features/With Mixed Features Specify if: With Onset During Intoxication/With Onset During Withdrawal 300.01 Panic Disorder Without Agoraphobia 300.21 Panic Disorder With Agoraphobia 300.22 Agoraphobia Without History of Panic Disorder 300.29 Specific Phobia Specify type: Animal Type/Natural Environment Type/ Blood-Injection-Injury Type/Situational Type/Other Type 300.23 Social Phobia Specify if: Generalized 300.3 Obsessive-Compulsive Disorder Specify if: With Poor Insight 309.81 Posttraumatic Stress Disorder Specify if: Acute/Chronic Specify if: With Delayed Onset 308.3 Acute Stress Disorder 300.02 Generalized Anxiety Disorder 293.84 Anxiety Disorder Due to . . . [Indicate the General Medical Condition] Specify if: With Generalized Anxiety/With Panic Attacks/With Obsessive-Compulsive Symptoms ____.__ Substance-Induced Anxiety Disorder (refer to Substance-Related Disorders for substancespecific codes) Specify if: With Generalized Anxiety/With Panic Attacks/With Obsessive-Compulsive Symptoms/With Phobic Symptoms Specify if: With Onset During Intoxication/With Onset During Withdrawal 300.00 Anxiety Disorder NOS SOMATOFORM DISORDERS 300.81 Somatization Disorder 300.82 Undifferentiated Somatoform Disorder 300.11 Conversion Disorder Specify type: With Motor Symptom or Deficit/With Sensory Symptom or Deficit/With Seizures or Convulsions/With Mixed Presentation 307.xx Pain Disorder .80 Associated With Psychological Factors .89 Associated With Both Psychological Factors and a General Medical Condition Specify if: Acute/Chronic 300.7 Hypochondriasis Specify if: With Poor Insight 300.7 Body Dysmorphic Disorder 300.82 Somatoform Disorder NOS 300.12 300.13 300.14 300.6 300.15 Dissociative Amnesia Dissociative Fugue Dissociative Identity Disorder Depersonalization Disorder Dissociative Disorder NOS Sexual and Gender Identity Disorders SEXUAL DYSFUNCTIONS The following specifiers apply to all primary Sexual Dysfunctions: Lifelong Type/Acquired Type Generalized Type/Situational Type Due to Psychological Factors/Due to Combined Factors SEXUAL DESIRE DISORDERS 302.71 Hypoactive Sexual Desire Disorder 302.79 Sexual Aversion Disorder SEXUAL AROUSAL DISORDERS 302.72 Female Sexual Arousal Disorder 302.72 Male Erectile Disorder ORGASMIC DISORDERS 302.73 Female Orgasmic Disorder 302.74 Male Orgasmic Disorder 302.75 Premature Ejaculation SEXUAL PAIN DISORDERS 302.76 Dyspareunia (Not Due to a General Medical Condition) 306.51 Vaginismus (Not Due to a General Medical Condition) SEXUAL DYSFUNCTION DUE TO A GENERAL MEDICAL CONDITION 625.8 Female Hypoactive Sexual Desire Disorder Due to . . . [Indicate the General Medical Condition] 608.89 Male Hypoactive Sexual Desire Disorder Due to . . . [Indicate the General Medical Condition] 607.84 Male Erectile Disorder Due to . . . [Indicate the General Medical Condition] 625.0 Female Dyspareunia Due to . . . [Indicate the General Medical Condition] 608.89 Male Dyspareunia Due to . . . [Indicate the General Medical Condition] 625.8 Other Female Sexual Dysfunction Due to . . . [Indicate the General Medical Condition] 608.89 Other Male Sexual Dysfunction Due to . . . [Indicate the General Medical Condition] Appendix DSM-IV-TR Classification ■ ____.__ Substance-Induced Sexual Dysfunction (refer to Substance-Related Disorders for substancespecific codes) Specify if: With Impaired Desire/With Impaired Arousal/With Impaired Orgasm/With Sexual Pain Specify if: With Onset During Intoxication 302.70 Sexual Dysfunction NOS PARAPHILIAS 302.4 302.81 302.89 302.2 Exhibitionism Fetishism Frotteurism Pedophilia Specify if: Sexually Attracted to Males/Sexually Attracted to Females/Sexually Attracted to Both Specify if: Limited to Incest Specify type: Exclusive Type/Nonexclusive Type 307.47 Parasomnia NOS SLEEP DISORDERS RELATED TO ANOTHER MENTAL DISORDER 307.42 Insomnia Related to . . . [Indicate the Axis I or Axis II Disorder] 307.44 Hypersomnia Related to . . . [Indicate the Axis I or Axis II Disorder] OTHER SLEEP DISORDERS 780.xx .52 .54 .59 .59 ____.__ 302.83 Sexual Masochism 302.84 Sexual Sadism 302.3 Transvestic Fetishism Specify type: Insomnia Type/Hypersomnia Type/Parasomnia Type/Mixed Type Specify if: With Onset During Intoxication/With Onset During Withdrawal Specify if: With Gender Dysphoria 302.82 Voyeurism 302.9 Paraphilia NOS GENDER IDENTITY DISORDERS 302.xx Gender Identity Disorder .6 in Children .85 in Adolescents or Adults Specify if: Sexually Attracted to Males/Sexually Attracted to Females/Sexually Attracted to Both/Sexually Attracted to Neither 302.6 302.9 Gender Identity Disorder NOS Sexual Disorder NOS Eating Disorders 307.1 Anorexia Nervosa Specify type: Restricting Type; Binge-Eating/Purging Type 307.51 Bulimia Nervosa Specify type: Purging Type/Nonpurging Type 307.50 Eating Disorder NOS Sleep Disorders PRIMARY SLEEP DISORDERS Dyssomnias 307.42 Primary Insomnia 307.44 Primary Hypersomnia Specify if: Recurrent 347 Narcolepsy 780.59 Breathing-Related Sleep Disorder 307.45 Circadian Rhythm Sleep Disorder Specify type: Delayed Sleep Phase Type/Jet Lag Type/Shift Work Type/Unspecified Type 307.47 Dyssomnia NOS Parasomnias 307.47 Nightmare Disorder 307.46 Sleep Terror Disorder 307.46 Sleepwalking Disorder Sleep Disorder Due to . . . [Indicate the General Medical Condition] Insomnia Type Hypersomnia Type Parasomnia Type Mixed Type Substance-Induced Sleep Disorder (refer to Substance-Related Disorders for substancespecific codes) Impulse-Control Disorders Not Elsewhere Classified 312.34 312.32 312.33 312.31 312.39 312.30 Intermittent Explosive Disorder Kleptomania Pyromania Pathological Gambling Trichotillomania Impulse-Control Disorder NOS Adjustment Disorders 309.xx Adjustment Disorder .0 With Depressed Mood .24 With Anxiety .28 With Mixed Anxiety and Depressed Mood .3 With Disturbance of Conduct .4 With Mixed Disturbance of Emotions and Condut .9 Unspecified Specify if: Acute/Chronic Personality Disorders Note: These are coded on Axis II. 301.0 Paranoid Personality Disorder 301.20 Schizoid Personality Disorder 301.22 Schizotypal Personality Disorder 301.7 Antisocial Personality Disorder 301.83 Borderline Personality Disorder 301.50 Histrionic Personality Disorder 301.81 Narcissistic Personality Disorder 301.82 Avoidant Personality Disorder 301.6 Dependent Personality Disorder 301.4 Obsessive-Compulsive Personality Disorder 301.9 Personality Disorder NOS ■ Appendix DSM-IV-TR Classification Other Conditions That May Be a Focus of Clinical Attention PSYCHOLOGICAL FACTORS AFFECTING MEDICAL CONDITION 316 . . . [Specified Psychological Factor] Affecting . . . [Indicate the General Medical Condition] Choose name based on nature of factors: Mental Disorder Affecting Medical Condition Psychological Symptoms Affecting Medical Condition Personality Traits or Coping Style Affecting Medical Condition Maladaptive Health Behaviors Affecting Medical Condition Stress-Related Physiological Response Affecting Medical Condition Other or Unspecified Psychological Factors Affecting Medical Condition MEDICATION-INDUCED MOVEMENT DISORDERS 332.1 333.92 333.7 333.99 333.82 333.1 333.90 Neuroleptic-Induced Parkinsonism Neuroleptic Malignant Syndrome Neuroleptic-Induced Acute Dystonia Neuroleptic-Induced Acute Akathisia Neuroleptic-Induced Tardive Dyskinesia Medication-Induced Postural Tremor Medication-Induced Movement Disorder NOS OTHER MEDICATION-INDUCED DISORDER 995.2 Adverse Effects of Medication NOS RELATIONAL PROBLEMS V61.9 Relational Problem Related to a Mental Disorder or General Medical Condition V61.20 Parent-Child Relational Problem V61.10 Partner Relational Problem V61.8 Sibling Relational Problem V62.81 Relational Problem NOS PROBLEMS RELATED TO ABUSE OR NEGLECT V61.21 Physical Abuse of Child (code 995.54 if focus of attention is on victim) V61.21 Sexual Abuse of Child (code 995.53 if focus of attention is on victim) V61.21 Neglect of Child (code 995.52 if focus of attention is on victim) ____.__ Physical Abuse of Adult V61.12 (if by partner) V62.83 (if by person other than partner) (code 995.81 if focus of attention is on victim) ____.__ Sexual Abuse of Adult V61.12 (if by partner) V62.83 (if by person other than partner) (code 995.83 if focus of attention is on victim) ADDITIONAL CONDITIONS THAT MAY BE A FOCUS OF CLINICAL ATTENTION V15.81 Noncomplicance With Treatment V65.2 Malingering V71.01 Adult Antisocial Behavior V71.02 Child or Adolescent Antisocial Behavior V62.89 Borderline Intellectual Functioning Note: This is coded on Axis II. 780.9 Age-Related Cognitive Decline V62.82 Bereavement V62.3 Academic Problem V62.2 Occupational Problem 313.82 Identity Problem V62.89 Religious or Spiritual Problem V62.4 Acculturation Problem V62.89 Phase of Life Problem Additional Codes 300.9 V71.09 799.9 V71.09 799.9 Unspecified Mental Disorder (nonpsychotic) No Diagnosis or Condition on Axis I Diagnosis or Condition Deferred on Axis I No Diagnosis on Axis II Diagnosis Deferred on Axis II Multiaxial System Axis I Clinical Disorders Other Conditions That May Be a Focus of Clinical Attention Axis II Personality Disorders Mental Retardation Axis III General Medical Conditions Axis IV Psychosocial and Environmental Problems Axis V Global Assessment of Functioning M U LT I A X I A L A S S E S S M E N T A multiaxial system involves an assessment on several axes, each of which refers to a different domain of information that may help the clinician plan treatment and predict outcome. There are five axes included in the DSM-IV multiaxial classification: Axis I Axis II Axis III Axis IV Axis V Clinical Disorders Other Conditions That May Be a Focus of Clinical Attention Personality Disorders Mental Retardation General Medical Conditions Psychosocial and Environmental Problems Global Assessment of Functioning The use of the multiaxial system facilitates comprehensive and systematic evaluation with attention to the various mental disorders and general medical conditions, psychosocial and environmental problems, and level of functioning that might be overlooked if the focus were on assessing a single presenting problem. A multiaxial system provides a convenient format for organizing and communicating clinical information, for capturing the complexity of clinical situations, and for describing the heterogeneity of individuals presenting with the same diagnosis. In addition, the multiaxial system promotes the application of the biopsychosocial model in clinical, educational, and research settings. The rest of this section provides a description of each of the DSM-IV axes. In some settings or situations, clinicians may prefer not to use the multiaxial system. For this reason, guidelines for reporting the results of a DSM-IV assessment without applying the formal multiaxial system are provided at the end of this section. AXIS I: Clinical Disorders— Other Conditions That May Be a Focus of Clinical Attention Axis I is for reporting all the various disorders or conditions in the Classification except for the Personality Disorders and Mental Retardation (which are reported on Axis II). The major groups of disorders to be reported on Axis I are listed in the box below. Also reported on Axis I are Other Conditions That May Be a Focus of Clinical Attention. When an individual has more than one Axis I disorder, all of these should be reported. If more than one Axis I disorder is present, the principal diagnosis or the reason for visit should be indicated by listing it first. When an AXIS I Clinical Disorders Other Conditions That May Be a Focus of Clinical Attention Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence (excluding Mental Retardation, which is diagnosed on Axis II) Delirium, Dementia, and Amnestic and Other Cognitive Disorders Mental Disorders Due to a General Medical Condition Substance-Related Disorders Schizophrenia and Other Psychotic Disorders Mood Disorders Anxiety Disorders Somatoform Disorders Factitious Disorders Dissociative Disorders Sexual and Gender Identity Disorders Eating Disorders Sleep Disorders Impulse-Control Disorders Not Elsewhere Classified Adjustment Disorders Other Conditions That May Be a Focus of Clinical Attention individual has both an Axis I and an Axis II disorder, the principal diagnosis or the reason for visit will be assumed to be on Axis I unless the Axis II diagnosis is followed by the qualifying phrase “(Principal Diagnosis)” or “(Reason for Visit).” If no Axis I disorder is present, this should be coded as V71.09. If an Axis I diagnosis is deferred, pending the gathering of additional information, this should be coded as 799.9. AXIS II: Personality Disorders and Mental Retardation Axis II is for reporting Personality Disorders and Mental Retardation. It may also be used for noting prominent maladaptive personality features and defense mechanisms. The ■ Appendix DSM-IV-TR Classification listing of Personality Disorders and Mental Retardation on a separate axis ensures that consideration will be given to the possible presence of Personality Disorders and Mental Retardation that might otherwise be overlooked when attention is directed to the usually more florid Axis I disorders. The coding of Personality Disorders on Axis II should not be taken to imply that their pathogenesis or range of appropriate treatment is fundamentally different from that for the disorders coded on Axis I. The disorders to be reported on Axis II are listed in the box below. In the common situation in which an individual has more than one Axis II diagnosis, all should be reported. When an individual has both an Axis I and an Axis II diagnosis and the Axis II diagnosis is the principal diagnosis or the reason for visit, this should be indicated by adding the qualifying phrase “(Principal Diagnosis)” or “(Reason for Visit)” after the Axis II diagnosis. If no Axis II disorder is present, this should be coded as V71.09. If an Axis II diagnosis is deferred, pending the gathering of additional information, this should be coded as 799.9. Axis II may also be used to indicate prominent maladaptive personality features that do not meet the threshold for a Personality Disorder (in such instances, no code number should be used). The habitual use of maladaptive defense mechanisms may also be indicated on Axis II. AXIS II Personality Disorders Mental Retardation Paranoid Personality Disorder Narcissistic Personality Disorder Schizoid Personality Disorder Avoidant Personality Disorder Schizotypal Personality Disorder Dependent Personality Disorder Antisocial Personality Disorder Obsessive-Compulsive Personality disorder Borderline Personality Disorder Personality Disorder Not Otherwise Specified Histrionic Personality Disorder Mental Retardation AXIS III: General Medical Conditions Axis III is for reporting current general medical conditions that are potentially relevant to the understanding or management of the individual’s mental disorder. These conditions are classified outside the “Mental Disorders” chapter of ICD-9-CM (and outside Chapter V of ICD-10). A listing of the broad categories of general medical conditions is given in the box below. As discussed in the “Introduction,” the multiaxial distinction among Axis I, Axis II, and Axis III disorders does not imply that there are fundamental differences in their conceptualization, that mental disorders are unrelated to physical or biological factors or processes, or that general medical conditions are unrelated to behavioral or psychosocial factors or processes. The purpose of distinguishing general medical conditions is to encourage thoroughness in evaluation and to enhance communication among health care providers. General medical conditions can be related to mental disorders in a variety of ways. In some cases it is clear that the general medical condition is directly etiological to the development or worsening of mental symptoms and that the mechanism for this effect is physiological. When a mental disorder is judged to be a direct physiological consequence of the general medical condition, a Mental Disorder Due to a General Medical Condition should be diagnosed on Axis I and the general medical condition should be recorded on both Axis I and Axis III. For example, when hypothyroidism is a direct cause of depressive symptoms, the designation on Axis I is 293.83 Mood Disorder Due to Hypothyroidism, With Depressive Features, and the hypothyroidism is listed again and coded on Axis III as 244.9. In those instances in which the etiological relationship between the general medical condition and the mental symptoms is insufficiently clear to warrant an Axis I diagnosis of Mental Disorder Due to a General Medical Condition, the appropriate mental disorder (e.g., Major Depressive Disorder) should be listed and coded on Axis I; the general medical condition should only be coded on Axis III. There are other situations in which general medical conditions are recorded on Axis III because of their importance to the overall understanding or treatment of the individual with the mental disorder. An Axis I disorder may be a psychological reaction to an Axis III general medical condition (e.g., the development of 309.0 Adjustment Disorder With Depressed Mood as a reaction Appendix DSM-IV-TR Classification ■ to the diagnosis of carcinoma of the breast). Some general medical conditions may not be directly related to the mental disorder but nonetheless have important prognostic or treatment implications (e.g., when the diagnosis on Axis I is 296.30 Major Depressive Disorder, Recurrent, and on Axis III is 427.9 arrhythmia, the choice of pharmacotherapy is influenced by the general medical condition; or when a person with diabetes mellitus is admitted to the hospital for an exacerbation of Schizophrenia and insulin management must be monitored). When an individual has more than one clinically relevant Axis III diagnosis, all should be reported. If no Axis III disorder is present, this should be indicated by the notation “Axis III: None.” If an Axis III diagnosis is deferred, pending the gathering of additional information, this should be indicated by the notation “Axis III: Deferred.” AXIS III General Medical Conditions (with ICD-9-CM codes) Infectious and Parasitic Diseases (001–139) Neoplasms (140–239) Endocrine, Nutritional, and Metabolic Diseases and immunity Disorders (240–279) Diseases of the Blood and Blood-Forming Organs (280–289) Diseases of the Nervous System and Sense Organs (320–389) Diseases of the Circulatory System (390–459) Diseases of the Respiratory System (460–519) Diseases of the Digestive System (520–579) Diseases of the Genitourinary System (580–629) Complications of Pregnancy, Childbirth, and the Puerperium (630–676) Diseases of the Skin and Subcutaneous Tissue (680–709) Diseases of the Musculoskeletal System and Connective Tissue (710–739) Congenital Anomalies (740–759) Certain Conditions Originating in the Perinatal Period (760–779) Symptoms, Signs, and Ill-Defined Conditions (780–799) Injury and Poisoning (800–999) AXIS IV: Psychosocial and Environmental Problems Axis IV is for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders (Axes I and II). A psychosocial or environmental problem may be a negative life event, an environmental difficulty or deficiency, a familial or other interpersonal stress, an inadequacy of social support or personal resources, or other problem relating to the context in which a person’s difficulties have developed. So-called positive stressors, such as job promotion, should be listed only if they constitute or lead to a problem, as when a person has difficulty adapting to the new situation. In addition to playing a role in the initiation or exacerbation of a mental disorder, psychosocial problems may also develop as a consequence of a person’s psychopathology or may constitute problems that should be considered in the overall management plan. When an individual has multiple psychosocial or environmental problems, the clinician may note as many as are judged to be relevant. In general, the clinician should note only those psychosocial and environmental problems that have been present during the year preceding the current evaluation. However, the clinician may choose to note psychosocial and environmental problems occurring prior to the previous year if these clearly contribute to the mental disorder or have become a focus of treatment— for example, previous combat experiences leading to Posttraumatic Stress Disorder. In practice, most psychosocial and environmental problems will be indicated on Axis IV. However, when a psychosocial or environmental problem is the primary focus of clinical attention, it should also be recorded on Axis I, with a code derived from the section “Other Conditions That May Be a Focus of Clinical Attention.” For convenience, the problems are grouped together in the following categories: ■ ■ Problems with primary support group—e.g., death of a family member; health problems in family; disruption of family by separation, divorce, or estrangement; removal from the home; remarriage of parent; sexual or physical abuse; parental overprotection; neglect of child; inadequate discipline; discord with siblings; birth of a sibling Problems related to the social environment—e.g., death or loss of friend; inadequate social support; living alone; difficulty with acculturation; discrimination; adjustment of life-cycle transition (such as retirement) ■ Appendix DSM-IV-TR Classification ■ ■ ■ ■ ■ ■ ■ Educational problems—e.g., illiteracy; academic problems; discord with teachers or classmates; inadequate school environment Occupational problems—e.g., unemployment; threat of job loss; stressful work schedule; difficult work conditions; job dissatisfaction; job change; discord with boss or co-workers Housing problems—e.g., homelessness; inadequate housing; unsafe neighborhood; discord with neighbors or landlord Economic problems—e.g., extreme poverty; inadequate finances; insufficient welfare support Problems with access to health care services—e.g., inadequate health care services; transportation to health care facilities unavailable; inadequate health insurance Problems related to interaction with the legal system/crime—e.g., arrest; incarceration; litigation; victim of crime Other psychosocial and environmental problems— e.g., exposure to disasters, war, other hostilities; discord with nonfamily caregivers such as counselor, social worker, or physician; unavailability of social service agencies When using the Multiaxial Evaluation Report Form, the clinician should identify the relevant categories of psychosocial and environmental problems and indicate the specific factors involved. If a recording form with a checklist of problem categories is not used, the clinician may simply list the specific problems on Axis IV. AXIS IV Psychosocial and Environmental Problems Problems with primary support group Problems related to the social environment Educational problems Occupational problems Housing problems Economic problems Problems with access to health care services Problems related to interaction with the legal system/crime Other psychosocial and environmental problems AXIS V: Global Assessment of Functioning Axis V is for reporting the clinician’s judgment of the individual’s overall level of functioning. This information is useful in planning treatment and measuring its impact, and in predicting outcome. The reporting of overall functioning on Axis V can be done using the Global Assessment of Functioning (GAF) Scale. The GAF Scale may be particularly useful in tracking the clinical progress of individuals in global terms, using a single measure. The GAP Scale is to be rated with respect only to psychological, social, and occupational functioning. The instructions specify, “Do not include impairment in functioning due to physical (or environmental) limitations.” The GAF scale is divided into 10 ranges of functioning. Making a GAF rating involves picking a single value that best reflects the individual’s overall level of functioning. The description of each 10-point range in the GAF scale has two components: the first part covers symptom severity, and the second part covers functioning. The GAF rating is within a particular decile if either the symptom severity or the level of functioning falls within the range. For example, the first part of the range 41–50 describes “serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting)” and the second part includes “any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).” It should be noted that in situations where the individual’s symptom severity and level of functioning are discordant, the final GAF rating always reflects the worse of the two. For example, the GAF rating for an individual who is a significant danger to self but is otherwise functioning well would be below 20. Similarly, the GAF rating for an individual with minimal psychological symptomatology but significant impairment in functioning (e.g., an individual whose excessive preoccupation with substance use has resulting in loss of job and friends but no other psychopathology) would be 40 or lower. In most instances, ratings on the GAF Scale should be for the current period (i.e., the level of functioning at the time of the evaluation) because ratings of current functioning will generally reflect the need for treatment or care. In order to account for day-to-day variability in functioning, the GAF rating for the “current period” is sometimes operationalized as the lowest level of functioning for the past week. In some settings, it may be useful to note the GAF Scale rating both at time of admission and Appendix DSM-IV-TR Classification ■ at time of discharge. The GAF Scale may also be rated for other time periods (e.g., the highest level of functioning for at least a few months during the past year). The GAF Scale is reported on Axis V as follows: “GAF =,” followed by the GAF rating from 0 to 100, followed by the time period reflected by the rating in parentheses—for example, “(current),” “(highest level in past year),” “(at discharge).” In order to ensure that no elements of the GAF scale are overlooked when a GAF rating is being made, the following method for determining a GAF rating may be applied: STEP 1: Starting at the top level, evaluate each range by asking “is either the individual’s symptom severity OR level of functioning worse than what is indicated in the range description?” STEP 2: Keep moving down the scale until the range that best matches the individual’s symptom severity OR the level of functioning is reached, whichever is worse. STEP 3: Look at the next lower range as a double-check against having stopped prematurely. This range should be too severe on both symptom severity and level of functioning. If it is, the appropriate range has been reached (continue with step 4). If not, go back to step 2 and continue moving down the scale. STEP 4: To determine the specific GAF rating within the selected 10-point range, consider whether the individual is functioning at the higher or lower end of the 10-point range. For example, consider an individual who hears voices that do not influence his behavior (e.g., someone with long-standing Schizophrenia who accepts his hallucinations as part of his illness). If the voices occur relatively infrequently (once a week or less), a rating of 39 or 40 might be most appropriate. In contrast, if the individual hears voices almost continuously, a rating of 31 or 32 would be more appropriate. In some settings, it may be useful to assess social and occupational disability and to track progress in rehabilitation independent of the severity of the psychological symptoms. GLOBAL ASSESSMENT OF FUNCTIONING (GAF) SCALE Consider psychological, social, and occupational functioning on a hypothetical continuum of mental healthillness. Do not include impairment in functioning due to physical (or environmental) limitations. ■ Appendix DSM-IV-TR Classification TABLE A.1 Code (Note: Use intermediate codes when appropriate, e.g., 45, 68, 72.) 100/91 Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms. 90/81 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members). 80/71 If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument), no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). 70/61 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. 60/51 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). 50/41 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). 40/31 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). 30/21 Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). 20/11 Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute). 10/1 Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death. 0 Inadequate information. The rating of overall psychological functioning on a scale of 0–100 was operationalized by Luborsky in the Health-Sickness Rating Scale (Luborsky L: “Clinicians’ Judgments of Mental Health.” Archives of General Psychiatry 7:407–417, 1962). Spitzer and colleagues developed a revision of the Health-Sickness Rating Scale called the Global Assessment Scale (GAS) (Endicott J, Spitzer RL, Fleiss JL, Cohen J: “The Global Assessment Scale: A Procedure for Measuring Overall Severity of Psychiatric Disturbance.” Archives of General Psychiatry 33:766–771, 1976). A modified version of the GAS was included in DSM-ILL-R as the Global Assessment of Functioning (GAF) Scale.